International School of Medicine

International University of Kyrgyzstan

Major "General Medicine"
Medical History in the discipline of "Therapy"

I. Passport part
1. Full Name: ---
2. Age: 63 years (date of birth: 01/01/1945)
3. Female gender
4. Profession: teacher
5. Date of admission to hospital: June 4, 2008
II. Complaints
· for paroxysmal (up to 10-15 times per day) cough, which occurs regardless of
physical activity, body position, and lasts 1-2 minutes, subsiding on its own;
· for the coughing up of hard-to-separate viscous mucopurulent sputum (about 20-
30 ml per day), without admixtures of blood, food, and odorless;
· shortness of breath with slight physical exertion (walking along the corridor at a
distance of 30-50 m), subsiding at rest when stopping after 2-3 minutes;
· an increase in body temperature (up to 37.3-37.5°C), mainly in the afternoon and
persisting for 3-5 hours. A decrease in temperature occurs independently or under
the influence of antipyretic drugs and is accompanied by profuse sweating;
· weakness, increased fatigue, decreased performance.
III. History of present illness (anamnesis morbi)
She fell ill about 6-7 days ago, when, without any visible provoking factors, the
patient first developed severe chills, a feeling of shortness of breath, and weakness.
Body temperature at this point in time increased to 38.7°C. The fever persisted for
the next 2 days with fluctuations from 37.6ºС to 39°С and was accompanied by
weakness and shortness of breath with little physical exertion. She did not go to
doctors, treated herself, took aspirin and Coldrex, after which her body temperature
dropped for a short time by about 1.0-1.5ºC.
At the end of the 2nd day of illness, constant moderate nagging pain appeared in
the right subscapular region, which sharply intensified at the height of a deep
inspiration. At the same time, a cough appeared, initially dry, and the next day with
a small amount of mucous sputum. The clinic doctor was called. Treatment with
Amoxiclav orally was prescribed (the patient does not remember the dose and
frequency of taking the tablets).
During the therapy, the patient’s health improved somewhat - the fever dropped to
low-grade levels (37.2ºC-37.5ºC), chest pain decreased, but the cough became
more intense with the release of a small amount of viscous mucopurulent sputum
without blood impurities. The cough especially bothered the patient at night when
she was in a horizontal position in bed. On the 4th-5th day of illness, shortness of
breath began to increase, which is why the tolerance to physical activity noticeably
decreased. The clinic doctor was called again, who strongly recommended that the
patient be hospitalized, and therefore the patient was admitted to the therapeutic
department of the hospital.
IV. Life history (Anamnesis vitae)
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

Born in 1943 in Moscow into a family of employees, the second child. She did not
lag behind her peers in development. Education – higher: graduated from the
Moscow State Pedagogical Institute.
Family and sexual history: menstruation since the age of 14 , after 28 days, 4 days
at a time, moderate, painless. Married since age 22. She had 2 pregnancies that
ended in two term births. Menopause at 55 years old. The climacteric period
proceeded without any special features.
Work history: She began working at the age of 22. After graduating from college
and until her retirement (at 55), she worked as a biology teacher at school.
Professional activity was associated with psycho-emotional stress.
No occupational hazards noted.
Throughout her life she lived in Moscow and was not in zones of environmental
disasters.
Food: high in calories, varied. In recent years, she has been trying to follow a diet.
Bad habits: does not smoke, does not drink alcohol, does not use drugs.
Past illnesses: in early childhood suffered from scarlet fever, measles, rubella, and
diphtheria. During her subsequent life she suffered from “colds” on average 1-2
times a year.
At the age of 52-53 years, she began to notice frequent headaches, which usually
occurred on the background of an increased blood pressure to 160/95 - 170/100
mm Hg. Hypertension was diagnosed, for which enalapril 10 mg per day and
atenolol 25 mg per day were prescribed, which the patient takes to this day. The
usual (“working”) blood pressure numbers on the background of regular therapy
are 140/85 – 135/80 mm Hg. Denies other diseases (including tuberculosis,
infectious diseases, liver, kidney, heart, gynecological diseases, etc.), as well as
injuries.
Epidemiological history:was not in contact with feverish and infectious patients, in
endemic and epizootic foci. There were no transfusions of blood, its components or
blood substitutes. No injections, surgeries, sanitation of the oral cavity, or other
medical procedures that violate the integrity of the skin and mucous membranes
have been performed over the past 6-12 months.
Allergy history: there were no allergic reactions to medications or foods.
V. Present state (status praesens)
GENERAL INSPECTION
General condition of the patient: moderate severity.
Consciousness: clear.
Position: active.
Body type: normosthenic constitutional type, height 168 cm, body weight 75 kg.
The posture is stooped, the gait is slow.
Body temperature: 37.3ºС.
Facial expression: tired.

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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

Skin, nails and visible mucous membranes. The skin is clean, pale with areas of
pigmentation of the skin of the feet and legs. There are no rashes or vascular
changes (rash, telangiectasia, spider veins and hemorrhages). Scars, visible tumors
and trophic changes in the skin are not detected. Moderate acrocyanosis is noted.
The skin is dry, its turgor is slightly reduced. Hair type is female.
Nails: the shape is correct (there are no changes in the shape of the nails in the
form of “hour glasses” or koilonychia). The color of the nails is pink, there is no
streaking.
Visible mucous membranes moderately bluish in color, moist; There are no rashes
on the mucous membranes (enanthems), ulcers, or erosions.
Subcutaneous fat: developed moderately and evenly. The thickness of the
subcutaneous fat layer at the navel level is 2.5 cm. There is no swelling or
pastiness. There is no pain or crepitus on palpation of subcutaneous fat.
The lymph nodes: The inguinal lymph nodes are palpable, about 1.0 cm in size,
soft, elastic, painless, easily displaced upon palpation. Occipital, parotid,
submandibular, cervical, supraclavicular, subclavian, ulnar and popliteal lymph
nodes are not palpable.
Pharynx: There is slight hyperemia of the pharynx, no swelling or plaque. The
tonsils do not protrude beyond the arches, are pink, without swelling or plaque.
Muscles: satisfactorily developed. Muscle tone and strength are slightly reduced.
There is no pain or hardness on palpation of the muscles.
Bones: Moderately severe scoliosis of the thoracic spine is noted. Palpation of the
4-7 spinous processes and paravertebral points of the thoracic spine is painful. The
shape of the other bones of the skeleton is not changed. There is no pain when
tapping the bones.
Joints: the configuration of the joints is not changed. There is no swelling and
tenderness of the joints when palpated, as well as hyperemia, or changes in the
temperature of the skin over the joints. Active and passive movements in the joints
in full. There is a crunching sound during active movements in the knee joints.
RESPIRATORY SYSTEM
Inspection
Nose: the shape of the nose is not changed, breathing through the nose is free.
There is no discharge from the nose.
Larynx: no deformation or swelling in the larynx area. The voice is quiet, clear.
Chest: the shape of the chest is hypersthenic. The supraclavicular and subclavian
fossae are pronounced. The width of the intercostal spaces is moderate. The
epigastric angle is obtuse. The shoulder blades and collarbones protrude clearly.
The chest is symmetrical. There is deformation (scoliosis) of the spinal column
along its entire length. The circumference of the chest is 86 cm during quiet
breathing, on inhalation – 89, on exhalation – 83. The excursion of the chest is 6
cm.

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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

Breathing: type of breathing – mixed. The right half of the chest lags behind when
breathing. Accessory muscles are not involved in breathing. The number of
respiratory movements is 20 per minute. Breathing is rhythmic, the duration of the
exhalation phase predominates. There is no visible difficulty breathing.
Palpation:
When palpating the VIII-X intercostal spaces on the right along the scapular line,
moderate pain is noted. Pain is also detected upon palpation of the 4-7 spinous
processes and paravertebral points of the thoracic spine. The elasticity of the chest
is reduced. Voice tremor is weakened in the subscapular and axillary region on the
right. The rest of the symmetrical areas of the chest are the same.
Percussion of the lungs:
With comparative percussion, a clear pulmonary sound is determined over
symmetrical areas of the lungs, with the exception of the subscapular and axillary
region on the right, where a distinct dullness is detected below the angle of the
scapula.
Topographic percussion:
Topographical
landmarks Right lung Left lung
Upper limit of the lungs
Front height of tops 3 cm above the collarbone
Height of the tops at
the back Spinous process of the VII cervical vertebra
Width of Kroenig
margins 5 cm
Lower border of the lungs
Parasternal line VI rib —
Midclavicular line VI rib —
Anterior axillary line VII rib VII rib
Median axillary line VII rib VIII rib
Posterior axillary line VII rib IX rib
Scapular line VII rib X edge
Spinous process of the VII Spinous process of the XI
Paravertebral line thoracic vertebra thoracic vertebra
The mobility of the lower edge of the lungs along all identification lines is 5 cm,
with the exception of the posterior axillary, scapular and paravertebral, where it is
absent.
Auscultation:
Main respiratory sounds: Below the angle of the scapula on the right
(corresponding to the 9-10 segment of the lower lobe of the right lung), breathing
is sharply weakened. Over the symmetrical areas of the remaining parts of the
chest, a slight weakening of vesicular respiration is noted.
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

Adverse respiratory sounds: Below the angle of the right scapula, a moderate
amount of moist, fine-bubbling sonorous wheezing is detected. No pleural friction
rub or crepitus can be heard.
Bronchophonia: in the area of dullness and sharp weakening of breathing on the
right below the angle of the scapula, whispered speech is not carried out.
CIRCULAR SYSTEM
Complaints:
Pain in the heart area, localized in the area of the apex of the heart, without
irradiation, of a compressive nature, lasting several minutes, occasionally
occurring during emotional stress, with increases in blood pressure. They usually
go away on their own or when blood pressure normalizes. Sometimes the patient
takes Corvalol to relieve pain.
Shortness of breath with minor physical activity (walking along the corridor at a
distance of 30-50 m), relieving at rest, when stopping after 2-3 minutes.
Palpitations, occasionally occurring when blood pressure rises, during emotional
stress or physical activity. The patient does not notice any interruptions in the
functioning of the heart.
There are no complaints about the appearance of edema.
Inspection:
Neck examination: external jugular veins and carotid arteries without visible
pathological changes. There is no swelling of the neck veins or increased pulsation
of the carotid arteries.
Examination of the heart area: the apical impulse is visible in the 5th intercostal
space on the left, 2 cm outward from the midclavicular line. Heart beat and
epigastric pulsation are not visually detected.
Palpation:
Apex beat: palpated 2 cm outward from the midclavicular line in the 5th intercostal
space, intensified, occupies the area of the 2 terminal phalanges of the middle
finger of the right hand.
Heart beat: not defined.
Epigastric pulsation: absent.
Trembling in the heart area(systolic or diastolic) is not determined.
There are no palpation pain and areas of hyperesthesia in the heart area.
Percussion:
Relative dullness of the heart:
Border
s Landmarks
Right Right edge of the sternum
2 cm outward from the left midclavicular line at the level of the 5th
Left intercostal space
Upper Upper edge of the third rib
The diameter of the relative dullness of the heart is 17 cm.
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

The width of the vascular bundle is 6 cm.

The heart configuration is normal.
Absolute dullness of the heart
Border
s Landmarks
Right Left edge of the sternum
3 cm medially from the midclavicular line at the level of the 5th intercostal
Left space
Upper IV rib
Auscultation:
Heart tones is rhythmic. Heart rate (HR) – 90 beats/min.
The first tone is loud, there is no splitting.
There is an accent of the second tone on the aorta. There are no splits or
bifurcations of the second tone.
There are no additional sounds (presystolic or protodiastolic gallop, mitral valve
opening tone, systolic gallop, etc.).
Noises:none.
Pericardial friction rub:absent.
VASCULAR STUDY
Arterial examination: The temporal, carotid, radial, femoral, popliteal, and
posterior tibial arteries are elastic and painless. There is no tortuosity of the
arteries. There is no aortic pulsation in the jugular fossa.
Noises or pathological sounds over the femoral and carotid arteries (double Traube
tone, double Vinogradov-Durozier murmur, etc.) are not heard.
Arterial pulse on both radial arteries the same, rhythmic, normal filling and
tension. The number of pulsations is 90 per minute.
Arterial pressure, measured by the Korotkoff method on the right and left brachial
arteries 145/90 mmHg.
Vein examination: The external jugular veins are not distended. A weak pulsation
of the neck veins (negative venous pulse) is detected. When listening to the jugular
veins, noises are not detected.
The veins of the chest, anterior abdominal wall, and limbs are not dilated, not
compacted, and are painless on palpation.
DIGESTIVE SYSTEM
Stomach achenone.
Dyspeptic symptoms there are no difficulty in swallowing, nausea, vomiting,
belching, heartburn and bloating.
Appetite preserved, no aversion to food (fatty, meat, etc.).
Chair: usually once a day, the amount is moderate. Feces are formed, brown in
color, with a normal odor. There is no blood or mucus in the stool.
Bleeding: There are no signs of esophageal, gastric, intestinal or hemorrhoidal
bleeding (vomiting blood, “coffee grounds”, scarlet blood in the stool, melena).
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

Inspection:
Oral cavity: the tongue is pink with a slight cyanotic tint, moist, without coatings.
Dentures. The gums, soft and hard palate are of normal color, there are no
hemorrhages or ulcerations. There is no bad breath.
Stomach: normal shape, the subcutaneous fat layer is developed moderately and
evenly. The abdomen is symmetrical, there are no protrusions or retractions. The
stomach is involved in the act of breathing. There is no visible intestinal peristalsis.
There are no venous collaterals of the anterior abdominal wall.
Abdominal circumference at the navel level is 80 cm.
Percussion:
Percussion sound is tympanic over the entire surface of the abdomen. There is no
free or encysted fluid in the abdominal cavity.
Palpation:
Superficial:the anterior abdominal wall is not tense, painless in all parts.
Symptoms of Shchetkin-Blumberg, Obraztsov, Murphy, Ortner, phrenicus
symptom are negative.
There is no discrepancy of the rectus abdominis muscles, no umbilical hernia, no
hernia of the linea alba. There are no superficially located tumor-like formations.
Methodical deep sliding palpation according to V.P. Obraztsov and N.D.
Strazhesko:The sigmoid colon is palpated in the left iliac region in the form of an
elastic cylinder, with a smooth surface 2 cm wide. Movable, not rumbling,
painless.
The cecum is palpated in a typical place in the form of a cylinder of elastic
consistency, with a smooth surface, 2 cm wide, mobile, not rumbling, painless.
The transverse colon is not palpable.
The ascending colon is not palpable.
The descending colon is not palpable.
The ileocecal angle is not palpable.
Stomach: greater curvature using the ausculto-percussion method and the method
of determining the splashing noise - at half the distance between the navel and the
xiphoid process. The greater and lesser curvature of the stomach and the pylorus
are not palpable.
Auscultation:
Normal intestinal motility is heard. There is no peritoneal friction noise. Vascular
murmurs in the area of the projection of the abdominal aorta and renal arteries are
not heard.
LIVER AND GALL BLADDER
Complaints:
The patient does not complain of pain in the right hypochondrium, dyspeptic
disorders, nausea, vomiting, belching, skin itching, icteric discoloration of the skin
and visible mucous membranes.
Inspection:
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

There is no protrusion in the area of the right hypochondrium. There is no

restriction in this area of breathing.
Percussion:
Boundaries of the liver according to Kurlov
Upper
Lines limit Bottom line
Right midclavicular
line VI rib 1 cm below the edge of the costal arch
Middle third of the distance from the navel to the
Anterior midline — xiphoid process
Left costal arch — Left parasternal line
Ortner's sign is negative.
Palpation:
The lower edge of the liver protrudes from under the costal arch by 1 cm, is
painless on palpation, elastic in consistency with a rounded edge.
Liver dimensions according to Kurlov
Dimension
Lines s
Right
midclavicular 10 cm
Anterior median 9 cm
Left costal arch 7 cm
Gallbladder: not palpable. Kerr's symptom and phrenicus symptom are negative.
Symptoms of Ortner and Vasilenko are not detected.
Auscultation:
There is no peritoneal friction noise in the area of the right hypochondrium.
SPLEEN
There are no complaints of pain in the left hypochondrium.
Inspection:
There is no protrusion in the area of the left hypochondrium, there is no restriction
in breathing in this area.
Percussion:
The longitudinal size of the spleen along the X rib is 7 cm, the transverse size is 5
cm.
Palpation:
The spleen is not palpable.
Auscultation:
There is no peritoneal friction noise in the left hypochondrium.
PANCREAS
There are no complaints of pain and dyspepsia, nausea and vomiting, diarrhea and
constipation. There is no thirst or feeling of dry mouth.
Palpation:
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

The pancreas is not palpable.

There is no pain in the pancreatic points of Des Jardins and Mayo.
URINARY SYSTEM
There are no complaints of girdle pain in the lumbar region, along the ureters or in
the lower abdomen.
Urination:the amount of urine per day is about 1.5 liters. There is no polyuria,
oliguria, anuria or ischuria.
Dysuric phenomena: none. Urination is not difficult. There is no cutting, burning,
pain during urination, or false urge to urinate. There is no pollakiuria or nocturnal
urination.
Urine straw yellow, transparent. There is no blood in the urine.
Inspection:
No visible changes were found in the lumbar region. There is no hyperemia of the
skin, swelling or smoothing of the contours of the lumbar region. There is no
limited bulging in the suprapubic region (after emptying the bladder).
Percussion:
Pasternatsky's symptom is negative on both sides. There is no dullness of
percussion sound above the pubis (after emptying the bladder).
Palpation:
The kidneys are not palpable. The bladder is not palpable. There is no pain on
palpation at the costovertebral point and along the ureters.
GENITAL SYSTEM
There are no complaints of pain in the lower abdomen, groin, lower back, sacrum,
or external genital area.
The genitals are developed correctly, hair growth is of the female type.
The development of primary and secondary sexual characteristics corresponds to
age.
ENDOCRINE SYSTEM
No complaints: in impaired growth, physique, marked increase in body weight or
exhaustion, excessive thirst, constant feeling of hunger, feeling of heat, sweating,
cramps. The patient notes muscle weakness, rapid fatigue, especially with an
increase in body temperature.
Inspection and palpation:
No disturbances in growth, physique or proportionality of individual parts of the
body were identified. The skin is moist. There is no hyperpigmentation, stretch
marks, or atypical hair growth. Evenly developed subcutaneous fat layer. There is
no increase in the size of the tongue, nose, jaws, ears, or moon-shaped face.
The soft, painless isthmus of the thyroid gland is palpated.
NERVOUS SYSTEM AND SENSE ORGANS
Complaints of headache, usually occurring when blood pressure rises. There is no
dizziness. Performance is reduced, attention is normal. Night sleep is not disturbed.
The mood is cheerful.
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

There is no impairment of skin sensitivity.

Visual and hearing acuity are reduced. The sense of smell is preserved.
Examination: Consciousness is clear, intelligence corresponds to the level of
development. The patient is balanced, sociable, calm. The gait is slow. Speech is
intelligible and clean.
VII. Examination plan:
1. Clinical blood test.
2. Clinical urine analysis.
3. Biochemical blood test: total protein, blood glucose, urea, creatinine, AST,
ALT, LDH.
4. X-ray of the chest organs.
5. Clinical analysis of sputum.
6. Bacteriological analysis of sputum.
7. ECG.
VIII. Data from laboratory and instrumental research methods, consultations
with specialists:
1. Clinical blood test: 06/5/08
Index Research result Norm
Hematocrit
Men 0.407-0.503
Women 0.37 0.361-0.443
Hemoglobin
Men 138 – 172 g/l
women 136 g/l 121 – 151 g/l
Red blood cells
Men 4.5-5.7 × 1012/l
Women 4.2 x 1012/l 3.9-5.0 × 1012/l
Leukocytes
White blood cell count14.7 × 109/l 3.8-9.80 × 109/l
Lymphocytes 3.6 × 109/l, or 25%1.2-3.0 × 109/l or 19-37%
Monocytes 0.7 × 109/l 0.1-0.6 × 109/l or 3-11%
Granulocytes 10.4 × 109/l 1.8-6.6 × 109/l
stab 1.4 × 109/l or 10% 0.04-0.3 × 109/l or 1-6%
segmented 10.5× 109/lily 72%2.0-5.5 × 109/l or 47-72%
ESR 42 mm/h 3 – 10 mm/h
Platelets 256 × 109/l 190-405 × 109/l
2. Biochemical blood test: 5.06.08
Index Research resultNormal indicators
Total protein67.1 g/l 65-85 g/l
Glucose 5.8 mmol/l 3.58-6.05 mmol/l
Creatinine 75 µmol/l 44-120 µmol/l
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

Urea 4.6 mmol/l 2.5 – 8.32 mmol/l

Amylase 28 units/l 35-118 units/l
AST 58 units/l 11-47 units/l
ALT 40 units/l 7 -53 units/l
LDH 347 units/l 90-280 units/l
KFK 64 units/l 30-220 units/l
CK MB* 7 units/l 0-12 units/l
K+ 4.6 mmol/l 3.4-5.3 mmol/l
Na+ 145 mmol/l 135 – 155 mmol/l
Ca++ 2.4 mmol/l 2.2-2.75 mmol/l
3. Urinalysis
General urine analysis5.06.06 Normal indicators
Qty 0.02
Color Yellow Straw yellow
Transparency TransparentTransparent
Reaction Sour slightly sour
Density 1015 1008-1025
Protein (quality) No No
Protein (sq.) No No
Protein (calc.) No No
Glucose (quality/) 0 not defined
Glucose (sq.) 0
4. Chest X-ray: 06/5/08
The pulmonary pattern is deformed. There is compaction of the lung tissue on the
right (segments 9-10). Diffuse pneumosclerosis. The root of the lung on the right is
expanded and dense. The aperture dome on the left is clear. On the right in the
pleural cavity there is a small amount of fluid, the level of which reaches the 9th
rib. Heart - waist smoothed. The shadow of the aorta is not expanded. The
mediastinal shadow is slightly expanded to the left. Conclusion: Polysegmental
pneumonia in the lower lobe of the right lung (9-10 segments of the right lung).
Pleural effusion on the right.
5. General sputum analysis dated June 5, 2008.
Sputum is a small amount, homogeneous, mucopurulent, odorless, neutral reaction;
microscopic examination reveals moderate numbers of alveolar macrophages and a
large number of neutrophils. There are few red blood cells. No malignant tumor
cells or mycobacterium tuberculosis were detected.
6. Bacterioscopic examination of sputum from 5.06.08
A large number of pneumococci are detected.
7. Study of pleural effusion
At the time of supervision, a diagnostic puncture of the pleural cavity to study
pleural fluid had not yet been performed.
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

8. ECG from 5.06.08

The sinus rhythm is correct. RR interval = 0.65 sec. Heart rate - 94 per minute; PQ
= 0.16 sec; QRS = 0.10sec; QT = 0.36 sec. PI, II Pv 6 widened; RI > RII > RIII ;
ST and T I, II, III, v6 - below the isoline; TV5-6 two-phase. Conclusion: sinus
tachycardia. Signs of left ventricular hypertrophy

1. Your diagnosis
2. Patient management tactics
3. Treatment

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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

For the examiner

Main diagnosis:Community-acquired (outpatient) bacterial polysegmental focal
pneumonia in the lower lobe of the right lung (segments IX-X), moderate severity.
Complications:Effusion into the pleural cavity on the right, respiratory failure
stage II.
Accompanying illnesses:Hypertension stage II, degree 1 (mild arterial
hypertension), high risk. Scoliosis of the thoracic spine.
RATIONALE FOR THE DIAGNOSIS:
The diagnosis was made based on the patient’s complaints:
· slight shortness of breath with little physical activity (walking along the corridor
at a distance of 20-30 m), with difficulty inhaling, subsiding with rest, when
stopping after 2-3 minutes;
· for moderate paroxysmal (up to 10-15 times per day) cough, regardless of
physical activity, body position, lasting 1-2 minutes, subsiding on its own,
· for the coughing up of viscous mucopurulent sputum (about 5-10 ml per day),
without admixture of blood, food, odorless,
· an increase in body temperature to 37.3-37.5°C, in the second half of the day,
persisting for 3-5 hours, decreasing on its own, accompanied by profuse sweating;
· weakness, decreased performance.
Based on the evolution of disease symptoms in the history of the present disease:
· sudden, without visible provoking factors, the appearance of fever, shortness of
breath, and unproductive cough, persisting over the next 6-7 days, the severity of
which changed against the background of anti-inflammatory antibiotic therapy;
· the appearance against this background of moderate in strength constant “pains”,
intensifying at the height of inspiration, with their subsequent decrease during
treatment,
· an increase in the severity of shortness of breath (!) against the background of a
decrease in pain, which was the reason for hospitalization in the hospital.
Based on direct examination data, the patient:
· slight acrocyanosis and cyanosis of mucous membranes;
· lag of the right half of the chest in breathing;
· absence of vocal tremor in the subscapular and axillary region on the right
(segment 9-10);
· dullness of percussion sound in this zone during comparative percussion; upward
displacement of the lower border of the lungs on the right (up to the 7th rib) along
the posterior axillary, scapular and paravertebral lines;
· sharp weakening of breathing in the zone of absence of vocal tremors and
dullness of percussion sound (IX-X segments on the right);
· the presence of a moderate amount of moist, finely bubbly sonorous wheezing.
13
 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

The diagnosis was confirmed by the results of additional research methods:

· leukocytosis, band shift in blood count and increase in ESR to 42 mm/hour;
· X-ray – compaction of lung tissue in the lower lobe of the right lung (segments
IX-X of the right lung); small effusion into the pleural cavity on the right.
X. Diagnosis of pathological syndromes
The detected signs of the disease can be grouped into the following syndromes:
1. Focal pulmonary compaction syndrome;
· pain (most likely associated with damage to the pleura due to the superficial
localization of the source of inflammation, which disappeared as a result of the
appearance of effusion into the pleural cavity);
· lag in breathing of the affected half of the chest,
· dullness of percussion sound in the projection of the lower lobe (segments 9-10)
of the right lung (due to compaction of the lung tissue and the appearance of
effusion in the pleural cavity),
· weakening of breathing in the dull area (effusion in the pleural cavity);
· moderate amount of moist fine-bubbling sonorous wheezing;
· X-ray data – compaction of lung tissue in the lower lobe of the right lung (S IX-
X); effusion into the pleural cavity on the right.
2. Respiratory failure syndrome;
· leukocytosis, band shift in blood count and increase in ESR to 42 mm/hour;
· shortness of breath (the degree of which increased against the background of
decreased pain (!)), 20 respiratory movements per minute at the time of
examination, at rest;
cyanosis of mucous membranes,
· tachycardia – heart rate 90 per minute.
3. Bacterial inflammation syndrome:
· leukocytosis, band shift in blood count and increase in ESR to 42 mm/hour;
increased body temperature (flat fever),
· leukocytosis, with an increase in the number of granulocytes and a band shift in
the blood count;
· hyperenzymemia (AST – 58 units/l and LDH – 347 units/l).
· increase in ESR;
· when examining sputum, it was mucopurulent; bacterioscopic examination
revealed pneumococcus.
The diagnosis of concomitant hypertension was made on the basis of:
· anamnestic indications of a previous increase in blood pressure and the use of
antihypertensive drugs;
· complaints of headaches, pain in the heart area, palpitations during physical and
emotional stress, as well as when blood pressure rises;
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 International School of Medicine
International University of Kyrgyzstan
Major "General Medicine"
Medical History in the discipline of "Therapy"

increased blood pressure detected during examination;

· presence of signs of strengthening of the apical impulse, its displacement to the
left;
· slight expansion of the left border of relative dullness of the heart;
· presence of accent II tone over the aorta;
· presence of electrocardiographic signs of left ventricular hypertrophy.

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